October 6, Re: Notice of Benefit and Payment Parameters for 2018; CMS-9934-P. Submitted electronically via

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1 20555 Victor Parkway Livonia, MI tel trinity-health.org October 6, 2016 Andrew M. Slavitt Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services CMS-9934-P 7500 Security Boulevard Baltimore, MD Re: Notice of Benefit and Payment Parameters for 2018; CMS-9934-P Submitted electronically via Dear Acting Administrator Slavitt, Trinity Health appreciates the continued opportunity to provide comments and information regarding the ongoing implementation of health insurance exchanges from the perspective of a large health care system. In this letter, we offer suggestions from our experience of having participated with multiple payers in various arrangements across Trinity Health markets since the inception of health insurance exchanges in 2014 and our recommendations related to the Centers for Medicare & Medicaid Services notice for comment CMS-9937-P, published in the Federal Register on August 29, Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. We are building a People-Centered Health System to put the people we serve at the center of every behavior, action and decision. This brings to life our commitment to be a compassionate, transforming and healing presence in our communities. Trinity Health includes 93 hospitals and 120 continuing care programs including PACE, senior living facilities and home care and hospice services that provide nearly 2.5 million visits annually. Committed to those who are poor and underserved, Trinity Health returns almost $1 billion to our communities annually in the form of charity care and other community benefit programs. We have 31 teaching hospitals with Graduate Medical Education (GME) programs providing training for 1,951 residents and fellows in 185 specialty and subspecialty programs. We employ approximately 97,000 full-time employees, including more than 5,300 employed physicians, and have more than 13,800 physicians and advanced practice professionals committed to 19 Clinically Integrated Networks across the country. Trinity Health applauds CMS efforts to promote the availability of high-quality, affordable health insurance through the federal and state exchanges. Trinity Health is aligned through its better health, better care, lower costs goals and is committed to the success of the exchanges, and has created programs and made resources available to help our patients and communities understand and enroll in health coverage. In the comments that follow, we offer our feedback in the following areas: Sponsored by Catholic Health Ministries

2 Permanent Risk Adjustment Program; Definition of Essential Community Providers; Surprise Bills; Differentiated Placement for Integrated Delivery Systems; Standardized Plan Options; and Barriers to Implementing Innovation. Permanent Risk Adjustment Program The proposed rule would ensure that the risk adjustment formula for 2017 considers partial year enrollments. In addition, beginning in 2018, the proposed rule would also incorporate modifications to account for data from prescription drug claims, to account for high cost cases, and to rebalance the rewards for high-risk and low-risk members. Trinity Health supports these changes as a short-term solution for issuers especially in light of recent announcements from our payer partners regarding their departures from the marketplace for We believe a longer term solution for the risk adjustment program is needed where CMS should consider adopting the CMS HCC risk model as applied to Medicare Part C in lieu of the CMS Commercial HCC risk model currently applied with proposed changes for the marketplace enrollees to prospectively risk adjust insurer payments. Doing so will provide standardization and efficiency and will leverage a model that has been vetted for over a decade. Proposed changes to the risk adjustment programs to account for partial year enrollments, to incorporate data from prescription drug claims, and to rebalance the rewards for high-risk and low-risk members, if implemented appropriately, can improve the accuracy of the risk scores. We acknowledge that even our best efforts to document diagnoses will fall short of being 100 percent complete and applaud CMS approach of supplementing claims data with prescription drug data. We share noted concerns about complexity and the potential for creating perverse incentives, and support the use of a hybrid model designed to overcome these challenges. We support the incorporation of high-cost risk in the risk adjustment model to adjust the for high-cost enrollees by excluding the percentage of costs above a threshold level. For year 1 of its introduction, we recommend the original threshold mentioned in the White Paper on $1 million with 80 percent coinsurance to stabilize it and evaluate the threshold for later years. We also encourage CMS to address the problem of some consumers coming in and out of the marketplace or delaying enrollment until they need care. The average medical loss ratio for enrollees purchasing during open enrollment versus special enrollment should be assessed. CMS is encouraged to further streamline and reduce the number of special enrollment periods (SEPs) and implement preenrollment verification for high-priority SEPs. Strengthening the SEP will help to stabilize the insurance marketplace ensuring reliable consumer access to care. Definition of Essential Community Providers Essential Community Providers (ECP) often provide services that are specifically developed to address the health needs of low income individuals, including language services, patient support services, coordination of health and social services, and locations in low-income communities. Trinity Health recognizes the value of ECPs and generally supports the inclusion of these providers in QHP networks. 2

3 Critical Access Hospitals, Rural Referral Centers, Disproportionate Share (DSH) and DSH-eligible Hospitals, and Sole Community Hospitals are all facilities that might be overlooked in the formation of a network if not for the ECP requirement. There is no other mechanism that would ensure their inclusion in a payer s network. On the other hand, pediatric and oncology services are both accounted for in network adequacy requirements. The provision of these services will be included as part of any adequate network without including Children s Hospitals and Free Standing Cancer Centers in the definition of ECPs. We are concerned that the inclusion of Children's Hospitals and Free Standing Cancer Centers in the definition does nothing to enhance the safety net, but has the unintended consequence of vesting in these providers undue influence in their negotiations with QHPs. Trinity Health recommends that the inclusion of Children s Hospitals and Free Standing Cancer Centers be regulated through network adequacy guidelines and that they be removed from the definition of ECPs. Doing so will level the playing field and should result in lower premiums without any compromise in quality. Surprise Bills CMS has also proposed changes to address surprise billing issues enrollees may encounter by requiring that a provider network count enrollee cost sharing for an Essential Health Benefit (EHB) provided by an out-of-network provider in an in-network setting under certain circumstances toward the annual cost sharing limit for that enrollee. CMS also provides issuers the option to provide written notice to an enrollee at least 10 business days before the service is received to notify them that additional costs may be incurred if they use an out-of-network provider (even if the service is received in an in-network setting). Trinity Health supports this change as a short-term solution for consumers until a longer term solution can be identified. One long term solution CMS should consider is to structure consumer protections similarly to requirements for enrollees who receive out-of-network emergency care. In these cases, a plan must pay out-of-network providers the highest of 1) in-network rates; 2) UCR (usual, customary and reasonable) rates; or 3) Medicare rates for that service. In so doing, the need for balance billing will be eliminated. Until then, consumers should be held harmless and payers held accountable. Differentiated Placement for Integrated Delivery Systems Trinity Health recognizes the benefits of tightly aligned provider networks and the contribution these networks can make in improving the experience of care, improving the health of populations, and reducing the per capita costs of health care. We agree with differentiating plans that utilize provider networks that are structured to achieve the goals of better health, better care and lower costs. Clinical integration and the benefits that flow from it are not limited to plans that provide a majority of covered professional services through physicians employed by the issuer. Trinity Health agrees conceptually with the additional language provided in the definition that contemplates networks that are comprised largely of a single medical group. However, we believe that a clearer definition would include language identifying clinically integrated networks rather than just a single medical group. The ability to successfully realize the goals of better health, better care and lower costs are through a group of aligned providers from the full continuum of care. The single contracted medical group language seems unduly focused on the physician community and does not account for the contributions of both physicians and facilities toward the goal of achieving these goals. We believe clinically integrated network language is more representative of what CMS is trying to achieve. 3

4 Standardized Plan Options While Trinity Health supports the concept of standardized plan options to promote consumer transparency and ease of plan comparison and shopping, we continue to believe the offering should be optional for issuers as proposed or be just as a measure to do apples to apples plan rate comparison for an average consumer. Trinity Health believes that if health savings account (HAS) plans are offered in the marketplace, significant education and value-based insurance design should be incorporated. It is important that enrollees understand when to select, and how to appropriately use, an HSA plan. We believe that many plan selections rely on premium price as the driving factor and that HSA plans could attract members who do not fully understand the benefits and limitations of such a plan. This is particularly important for enrollees with chronic health conditions. The financial barriers created by HSA plans to patients seeking primary care and preventive care make managing the health of a population difficult. If HSA high-deductible plans are offered in the marketplace, they should adopt a flexible benefit design that offers protection for certain medical services through a value-based insurance design plan structure. CMS is encouraged to work with the V-BID Center to develop innovative plan designs. A targeted strategy exploring coverage for certain high-value, clinically-indicated health services prior to meeting the deductible will produce more effective high-value health plan designs. Barriers to Implementing Innovation Trinity Health is dedicated to the goals of better health, better care and lower costs and believes that the provider network should be delegated more of the essential population health services around care management, case management, disease management, and utilization management. We would like to see more member education to establish stronger relationships with their PCPs to enable the coordinated care that we believe will allow us to be successful in achieving these goals. We believe that there needs to be more timely and transparent sharing of claims information to enable the population health management functions outlined above. We encourage CMS to continue to adopt policies that empower the provider network to be more effective in their population health efforts. CMS is encouraged to work with states to permit innovative state-level solutions. Given statutory limitations on federal action, we encourage CMS to assist states in developing state-level solutions. For example, states may consider wrap-around risk-adjustment, reinsurance and risk corridor programs. Additionally, CMS should work with state regulators to promote fair and sustainable plan pricing. We understand that states evaluation of rate proposals may be challenged by lack of consistency in how plans report financial information. Therefore, we urge CMS to work with state regulators and the National Association of Insurance Commissioners (NAIC) to improve oversight of and consistency in plans financial reporting, which will help states to evaluate proposed rates. Finally, Trinity Health believes additional innovation is necessary to attract and enroll middle income eligibles. A recent study by Avalere Health suggests 80 percent of eligibles with incomes below 150 percent of the federal poverty level have enrolled in marketplace products; yet only 17 percent of eligibles with incomes from three to four times the poverty level are enrolling. Expanding participation in the marketplace via innovative methods targeting all subsidy-eligible individuals will reduce the number of uninsured, help stabilize risk pools, and promote more affordable premiums. 4

5 Conclusion Trinity Health is appreciative of the opportunity to comment on the Notice of Benefit and Payment Parameters and thanks CMS for engaging with stakeholders throughout this process. We believe that the health insurance exchanges represent an ongoing opportunity to reach uninsured consumers and provide comprehensive, high-quality coverage to a range of individuals. We support a regulatory framework that promotes transparency, protects patients, and ensures that no groups are excluded from the opportunity to enroll in QHPs on the basis of health status, income, or ethnicity. If you have any questions on our comments that follow, please feel free to contact me at wellstk@trinity-health.org or Sincerely, Tonya K. Wells Vice President, Public Policy & Federal Advocacy Trinity Health 5